The Patient Stalkers
This was surely a victory for the people. We have lost, over the past 20 years, all kinds of public services, but next month one is due to expand. After heavy bludgeoning by the government, Britain's general practitioners have agreed to open their surgeries late into the evening and on Saturday mornings. As Gordon Brown says, the health service is "too often centred on the needs of the providers rather than those of patients."(1) Now we will have a service better matched to the pattern of our lives.
This, at any rate, is the government's story, and at first sight it is plausible. The truth, as always, is stranger and more complex. It begins with a bare-faced lie.
The government launched its campaign a year ago, with a press release published by the Department of Health. This claimed that a report by the Cabinet Office, published the same day, "reveals that nine out of ten" people polled "said they want public services, such as GP surgeries, that are open some evenings and weekends, even if that means they would sometimes be shut during the working week."(2) This was reported verbatim by the press(3), but it was a complete fabrication. I have read the report(4). It contains no mention of this poll, or anything resembling it. The terms "surgeries", "evening", "weekend" and "working week" do not occur.
But on the strength of this fiction, extended opening hours became government policy. It is a bit like the war with Iraq: the decision to go ahead was made before the evidence materialised. Just as the government was publishing its misleading press release, Ipsos Mori was completing the huge poll - of 2.6 million people - that the same department had commissioned. This, surely, would support its fictitious claim. Who would not welcome longer opening hours?
To the department's intense discomfort, Ipsos Mori found that "the vast majority of patients (84%) say they are satisfied with the hours their GP practice was open during the last six months"(5). Those who must visit GPs most often are the most relaxed about opening hours: only among 18-34 year olds - the healthiest section of the population - does the level of unhappiness rise above 20%(6), and then only by a whisker.
But, like the weapons of mass destruction, if the government said the public demand was there, it had to be. On Thursday Gordon Brown insisted that "people want weekend opening; people want to be able to see their GP in the evenings."(7) Yes, some people do, but not very many.
The Confederation of British Industry was also unhappy with the results. It commissioned another survey, again from Ipsos Mori. This received responses from just 1,014 people - one 2,500th of the department's sample size. It asked a slightly different question: "how easy or difficult was it to get an appointment at a time that was convenient to you?". Thirty-one percent said they had found it "fairly or very difficult"(8).
The CBI issued a report claiming that "a commonly heard complaint is that GP practices are not open at weekends, early in the morning or in the evening … GP services are not responding to clear signals for change from patients"(9). But it produced no evidence: the survey didn't ask about opening times. There are plenty of reasons why patients might have found it difficult to get a convenient appointment.
But even if the government is using dodgy figures and has misjudged popular support, what's wrong with longer opening hours? Strange to relate, quite a lot. In some places, where there are large numbers of commuters who travel far to work, it makes sense. But Gordon Brown wants to impose it on surgeries everywhere.
This means, in effect, transferring resources from children, the old and the very sick to working people, who need the services least. GPs will have to work shifts, which undermines one of the most important foundations of the NHS: the continuity of care. It is not clear that longer opening times will in reality be much more convenient for working patients: the appointment clerks, specialist nurses, consultants, physiotherapists, dentists, X-ray departments, biochemistry labs, blood sampling services and computer technicians with whom GPs work are not available in the evenings and at weekends(10), so patients might have to come back to complete the consultation. If the government wants a genuine health supermarket, open all hours, it will have to pay much, much more.
So why is it so keen on this reform? Because it assists a quite different agenda. To avoid the political firestorm big business rains on any government that stands in its way, Gordon Brown must make constant concessions. What business wants most is the 40% of the economy controlled by the state. He must find clever and camouflaged means of delivering it that do not prompt us to take to the streets.
This means waging a public relations war against GPs and the other public sector dinosaurs who impede choice and change. It means a thousand small steps towards privatisation. The government is expanding the number of independent sector treatment centres, even though they turn out to be far less efficient than the NHS and leave the taxpayer with major liabilities(11). It is opening staggeringly expensive polyclinics, operating seven days a week, which will be run by multinational companies(12). It will allow the primary care trust in Birmingham to shut the city's surgeries and replace them with primary care units franchised to corporations - the promoter of this scheme happily admits to modelling it on McDonalds(13). It is transferring GPs' surgeries to supermarkets (the first was opened by Sainsbury's last week(14)) and giving high-street chemists responsibility for diagnosing and treating minor ailments, even though they are not qualified to tell the difference between an ordinary cough and lung cancer. No minister can now discuss the NHS without mentioning "new providers" or "alternative providers", which is their code for private companies, or "choice" and "reform", which means privatisation.
The CBI has produced a long list of complaints about GPs' failure to "rise to the challenge" of the market(15). In truth they are among the most efficient workers in the NHS. One of the reasons why their pay has jumped so quickly is that they have responded more effectively than the government expected to the incentives in their new contract (giving the government a further stick with which to beat them). They are way ahead of the hospitals in their use of information technology. But there is money in primary care, which is why they are now in the firing line. GPs say that the government was hoping they would reject its demand for longer opening hours, knowing that the private sector could then step into the breach.
None of this serves either the customer or the taxpayer. The irony of Brown's reforms is that they are wholly centred on the needs of the providers rather than the patients - as long as the providers are corporations. So don't wait to take to the streets. Little by little, the privatisation of the NHS is happening already, disguised as a crusade for patient power.
1. Gordon Brown, 7th January 2008. Speech on the National Health Service.
2. Department of Health, 19th March 2007. More family doctor services for deprived areas.
3. Eg Sarah Hall, 19th March 2007. Fruit, veg and a trip to the GP as stores are asked to open surgeries. The Guardian.
4. Prime Minister's Strategy Unit, March 2007. Policy review - Building on progress: Public services.http://archive.cabinetoffice.gov.uk/policy_review/documents/building_on_progress.pdf
5. Department of Health, 2007. The GP Patient Survey 2006/2007: National Report, p58.http://www.dh.gov.uk/en/Publicationsandstatistics/PublishedSurvey/GPpatientsurvey2007/DH_075127
6. ibid, p60.
7. Gordon Brown, quoted by Daniel Martin, 7th March 2008. GPs grudgingly agree to work evenings and weekends at last. Daily Mail.
8. LLM Future Services, 2007. Survey conducted for CBI, May 30th-31st 2007. Sent to me by the CBI.
9. Confederation of British Industry, 18th September 2007. Just What the Patient Ordered: Better GP Services.http://www.cbi.org.uk/ndbs/press.nsf/0363c1f07c6ca12a8025671c00381cc7/f60cebe0663c98d68025734600573f81/$FILE/CBI%20report%20'Just%20what%20the%20patient%20ordered'%20September%202007.pdf
10. Gruffydd Penrhyn Jones, GP, pers comm.
11. Allyson M Pollock and Sylvia Godden, 23rd February 2008. Independent sector treatment centres: evidence so far. British Medical Journal, vol 336, pp421-424. doi:10.1136/bmj.39470.505556.80
12. See British Medical Association, January 2008. Access to GP services in England.http://www.bma.org.uk/ap.nsf/Content/Gpaccess.
13. Nick Britten, 4th February 2008. GP surgeries 'could be run by Tesco or Virgin'. Daily Telegraph.
14. Hugh Wilson, 4th March 2008. The Sainsbury's GPs: checkout, then check-up. The Guardian.
15. See Confederation of British Industry, 18th September 2007, ibid.
Published in the Guardian 10th March 2008.